Burnout syndrome and nurse-to-patient ratio in the workplace
Nurse Leader Effect on Burnout Among Mental Health Nurses ...
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Bethel University Bethel University
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All Electronic Theses and Dissertations
2017
Nurse Leader Effect on Burnout Among Mental Health Nurses Nurse Leader Effect on Burnout Among Mental Health Nurses
Working in Inpatient Psychiatric Nursing Working in Inpatient Psychiatric Nursing
Beatrice Masita Paintsil Bethel University
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NURSE LEADER EFFECT ON BURNOUT AMONG MENTAL HEALTH NURSES WORKING IN INPATIENT PSYCHIATRIC NURSING
A MASTER’S PROJECT SUBMITTED TO THE GRADUATE FACULTY
OF THE GRADUATE SCHOOL BETHEL UNIVERSITY
BY BEATRICE MASITA PAINTSIL
IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF
MASTERS OF SCIENCE IN NURSING
DECEMBER 2017
Bethel University
Nurse Leader Effect on Burnout Among Mental Health Nurses Working in Inpatient
Psychiatric Nursing
Beatrice Masita Paintsil
December 2017
Approved: Bernita Missal PhD, RN……………Thesis Advisor Bernita Missal PhD, RN
Approved: Diane Dahl PhD, RN…………….....Dean of Nursing
Approved: Pamela K. Friesen PhD, RN…………Director of Graduate Nursing Program
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Acknowledgement
I am amazed and humbled by the goodness, mercy, and the grace of God for
completing this program. There were times when I truly didn’t have it in me to keep
going but I know it had to be God. I thank God, every day for the work that he is doing
in me. I can’t wait to see where he takes me next.
I would like to sincerely thank my husband, Felix for the incredible support that
he accorded me throughout my master’s program. Thank you for caring for our children
when I couldn’t, for staying up late with me as I completed assignments, for cheering me
on and encouraging me when I was down and for praying me through. For helping me
with technology and for being patient with me. You are my rock. To my children, thank
you Sean and Sydney for reminding me to do my homework. Thanks for the hugs and for
coming to the library with me. I love you guys. Thanks Sheila, for your support and
encouragement. To my sister Josephine, thank you for being in the program with me and
reminding me that assignments are due. To my dear friend Carol, thank you for caring for
my kids so that I could study, you are a friend indeed.
To my parents, thank you for instilling the value of hard work in me and for
showing me the way. Thanks daddy, for reminding me that I needed to go back to school.
This accomplishment is for you.
To my professors at Bethel, thank you for being patient, for seeing potential in
me, for encouraging and guiding me. A special thank you to Dr. Bernita Missal for being
my advisor and for believing in me, encouraging me and cheering me on. Thank you for
your prayers and smile. I will be forever grateful.
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Abstract Background: Burnout is a phenomenon that affects many nurses working in different
nursing specialties. Research has shown that nurses working in psychiatry suffer from
burnout. Burnout can have serious consequences to the individual nurse, to the patients
they are responsible for, and the organization as a whole.
Purpose: The purpose of this critical review of the literature is to explore the impact
nursing leadership can have on burnout among mental health nurses
Conceptual Framework: The Modeling and Role-Modeling theory will be adapted to
guide the review and to explain the human relationship of nurse leaders and mental health
nurses in the context of reducing and preventing burnout.
Methods: Twenty qualitative and quantitative studies were reviewed. The Johns Hopkins
Research Evidence Appraisal Tool as well as the Johns Hopkins Non-Research Evidence
Appraisal Tool (Dearholt & Dang, 2012), were used to evaluate the strength of the
research evidence.
Results: The literature reviewed identified that nursing leadership involvement in the
inpatient psychiatry units has a positive impact on nurse burnout. The presence of nurse
leaders protects nurses against depersonalization, increases job satisfaction, provides
clinical supervision, enhances effective communication, and ensures nurses have the
resources they need to succeed.
Conclusion: The presence of nursing leadership on inpatient psychiatry units is
important as it protects mental health nurses from burnout. When leaders are visible,
nurses feel supported and valued. Nursing leadership ought to work collaboratively with
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mental health nurses, and include the nurses’ input in departmental decisions that affect
them.
Implications: Nurse leaders in psychiatry need to be trained in interpersonal
communication as well as in clinical supervision. Education and interventions to both
staff and leaders about the effects of burnout is necessary to protect against burnout.
More research is needed to explore the unique leadership qualities that are needed for
leaders who work in inpatient psychiatry. Also, more research is needed to explore
unique leadership needs for psychiatric care environments.
Key words: Nurse burnout, nursing leadership, psychiatric nurses, mental health nurses,
Nursing management, stress, and coping
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Table of Content
Acknowledgement……………………………………………………………………....3
Abstract………………………………………………………………………………….4
Chapter One: Introduction………………………………………………………………8
Statement of Purpose…………………………………………………………….9
Evidence that Warrants Literature Review ....................................................... …9
Significance to Nursing ......................................................................................... 11
Conceptual Framework ........................................................................................ 12
Chapter Two: Methods………………………………………………………………….16
Search Strategies………………………………………………………………...16
Criteria for Including or Excluding Research Studies…………………………..16
Number and Types of Studies for the Review…………………………………..17
Criteria for Evaluating Research Studies………………………………………..17
Chapter Three: Literature Review and Analysis………………………………………...19
Synthesis of Major Findings ................................................................................ 19
Leader - Nurse Communication and Burnout…………………………...19
Clinical Supervision and Burnout ............................................................ 20
Psychiatric Work Environment and Burnout ........................................... 22
Leadership Style and Burnout…………………………………………...24
Critiques Salient Studies………………………………………………………...25
The Literature Matrix…………………………………………………………...28
Chapter Four: Discussion, Implications, and Conclusions……………………………...48
Historical and Current Trends and Gaps in the Literature ................................... 48
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Discussion……………………………………………………………………….49
Implications for Nursing Practice……………………………………………….51
Implication for Nursing Education……………………………………………...53
Recommendation for Nursing Research………………………………………...53
Integration and Application of Selected Theoretical Framework……………….53
Conclusion……………………………………………………………………....57
References…………………………………………………………………………….....58
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Chapter One: Introduction
Burnout has been defined as a syndrome of physical and emotional exhaustion
frequently seen among individuals who work in the caring professions (Maslach, Jackson
& Leiter, 1996). It is a gradual process whereby an individual in response to prolonged
stress detaches from work and other relationships. Maslach, Jackson and Leiter (1996)
describe psychological burnout as a syndrome consisting of three essential
characteristics: emotional exhaustion, which describes a reduction in the emotional
resources of an individual, depersonalization, which is characterized by an increase in
negative, cynical, and insensitive attitudes towards patients, and low personal
accomplishment, which refers to a feeling of being unable to meet patients' needs and to
satisfy essential elements of job performance.
Symptoms associated with burnout include, low energy, feelings of lack of
control and helplessness, lowered motivation to engage in work, and negative attitude
towards self, work, and others. In Psychiatry, nurses are often subjected to both physical
and verbal aggression from their patients. Research has shown that when nurses are
frequently subjected to violence or threats of violence they can become desensitized,
suffer emotional, physical and psychological health problems (Bimenyimana,
Poggenpoel, Myburgh, & Van Niekerk, (2009); Levert, Lucas & Ortlepp (2000); Ahola
& Hakanen (2014); Furtado, Batista, & Silva (2011).
Research has also shown that nurses in leadership positions may play an
important role in alleviating burnout (Furtado, Batista & Silva, 2011). For this review, the
terms psychiatric nurse(s) and mental health nurse(s) will be used to refer to nurses who
work with mentally ill patients and will therefore be used interchangeably.
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Statement of Purpose
This critical review of the literature will explore the issue of nurse burnout in
mental health nursing. In particular, the study will be focused on the role that nursing
leadership can play in reducing and preventing burnout among mental health nurses who
work in inpatient psychiatry. The review intends to find out what impact nurse leader
involvement on inpatient psychiatry units has on burnout among mental health nurses.
Evidence That Warrants Literature Review
Dickson and Wright (2008) observed that nurses, in general, and mental health
nurses, in particular, are at risk for burnout because they are constantly interacting with
patients. Pompili et al. (2006), also found that psychiatric nurses experience higher levels
of burnout than nurses in other specialties. Burnout is costly and wasteful because it more
often than not leads to nurse turnover, and organizations have to spend a lot of money
recruiting and training new nurses. According to Hoge et al. (2007), burnout has been
identified by the United States Federal government as a key component of the major
problem of retaining competent nursing staff in treatment facilities and state behavioral
health systems. In the period 2003-2004 out of 18.2 % of psychiatric nurses who left the
specialty, 26% of the nurses left due to burnout as compared to illness (15%), disability
(15%), other position (13%), and promotion (12%).
Recently, inpatient psychiatric services have moved from state institutions to
hospital settings. The patient population in inpatient psychiatry units has thus changed to
include populations that were normally referred to state institutions. This has resulted in
high patient turnover (National Association of Psychiatric Health Services, (NAPHS),
2006) which leads to high readmission rates, overcrowding in inpatient psychiatry units
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and increase in patient aggression leading to frequent use of restraints and seclusion. This
has resulted in nurse burnout and injury which, leads to medication errors, and other
negative patient outcomes (Hanrahan, 2010; Rothschild et al., 2007). The problem is
made worse by a nursing shortage in general and a serious shortage of psychiatric nurses
(Hanrahan, 2009). In 2006, a study on hospital based psychiatric nursing shortages by the
National Association of State Mental Health Program Directors Research Institute found
that 36 out of 43 states had psychiatric nurse vacancies in hospital settings (NASMHPD
Research Institute, 2006). The nursing shortage and the admission of more violent
patients (who would have previously been referred to state facilities) increased the
workload of mental health nurses and consequently increased burnout.
Additionally, nursing care has expanded and nurse managers are often responsible
for large-scale policy planning, staff management, financial resource management, and
business management, in addition to their core responsibilities of coordinating and
supervising the delivery of health care. Due to the increased responsibilities of nursing
leaders it has been observed that the leaders are more often than not in their offices and
far removed from bedside nursing. They are involved in administrative duties and only
show up on the unit floor when there is a problem or when the regulatory bodies like The
Joint Commission are expected to visit the hospital. In many cases the leaders are not
aware of the issues that are facing staff nurses and are therefore not in a position to notice
the stress that the nurses have to undergo every day. A study that examined how
organizational factors of the inpatient psychiatric environments are associated with
psychiatric nurse burnout found that psychiatric nurse burnout is associated with
unsupportive management (Hanrahan et. al. 2008).
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Different interventions have been employed to ameliorate the high burnout in
nurses. This review of the literature aims to find out what impact psychiatric nursing
leadership involvement on inpatient psychiatry units has on nurse burnout. Research in
other areas of nursing shows that there is a positive relationship between the degree to
which the staff nurses feel that they are valued by their leaders and the organization and
the degree of nurse burnout (Kanai-Pak, Aiken, Sloane, & Poghosyan, 2008; Poghosyan,
Aiken, & Sloane, 2009). It is therefore imperative to review the literature in order to
identify the impact of competent nursing leaders and which leadership styles can be
applied in inpatient psychiatry units to prevent burnout.
Significance of the Research to Nursing
This review of literature highlights the impact that nurse leaders’ presence on
inpatient psychiatry units can have and outlines guidelines for addressing the problems
that lead to nurse burnout among nurses working in psychiatry. This project provides a
positive strategy for nurse leaders’ involvement in inpatient psychiatry units as a basis of
supporting nurses in their nursing roles in order to prevent burnout and provide positive
work environments in which nurses thrive and clinical best practice is delivered.
With nursing shortages being experienced in all sectors of nursing, mental health
nursing is not exempt (Hanrahan, 2009). It is therefore important to care for the nurses
that are in the workforce and empower them to stay in psychiatric nursing and be the best
nurses that they can be. While nurse leaders have the responsibility of holding nurses
accountable for the job that they are hired to do, they also must carry the burden of
supporting the nurses and empowering them to succeed. Nurse leaders cannot support the
nurses unless they are physically on the floor listening, discussing, and engaging the
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nurses in open dialogue on ideas that would improve the working conditions of the nurses
while at the same time providing validation of the work that the nurses are doing every
day. Being on the nursing unit allows leaders the opportunity to mentor nurses, foster best
practices and find workable solutions for department issues (Silvers, 2017). In addition,
when leaders are visible on the unit, their presence is perceived as caring for the nurses,
and the leaders on the unit can model healthy, professional, and supportive behaviors for
the nurses (Silvers, 2017).
Conceptual Framework
Working with mentally ill patients can be stressful. Some of the stressors include,
heavy workload, lack of positive feedback and support from nurse leaders, lack of
resources, poor work environments, the stigma associated with working in psychiatry,
and the emotional stress of working with aggressive patients (Paris & Hoge 2010). It is
therefore important to have good working relationships as nurses depend on each other to
ensure safety of the patients as well as safety for coworkers
The theory of Modeling and Role-Modeling (MRM), which is a relationship based
theory, will be applied as a framework in this review of the literature as it places the client
at the center of all nursing care. This theory was selected as a conceptual framework for
this review because at its core is the emphasis on seeing issues as the person affected sees
them. The theory recognizes the role of the patient as the expert in their illness and
therefore in the best position to identify what they need. In MRM, modeling is the act of
gaining understanding of the client’s world from the client’s perspective. According to
Erickson, Tomlin and Swain (1983), the MRM theory proposes that nurses should
attempt to view the world through the client’s eyes. Role-Modeling
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then is using the client’s model, to plan interventions and provide resources that meet
his/her perceived needs. Concepts of this theory that are related to the nurse’s role
include, facilitation, nurturance, and unconditional acceptance. The theory views the
client in a holistic sense as someone who has physical, emotional, biological, spiritual,
and psychological needs. The MRM theory provides the nurse a basis for providing
patient centered care and allows the nurse the opportunity to provide holistic care.
There are five aims of nursing interventions when using the MRM theory. They
are, building a trusting relationship with patients, promoting hope and positive self-
esteem, promoting the patient’s idea of control, assisting patients to determine and
engage their strengths, setting goals that have been mutually agreed upon by patient and
nurse that promote health and allow the client’s basic needs to be met. All the above
interventions are meant to enable the patient to attain self-care. The concept of self-care
is huge in the MRM theory. The theory proposes that individuals know, on some level,
why they are unwell and how to get better. Through the process of modeling, nurses are
able to understand the patient’s perceived personal problems. When using the MRM
theory nursing interventions are designed based on the belief that patients understand
why they are ill and that they also know what they need to do to improve and optimize
their state of health and promote their well-being. The MRM theory refers to this inherent
knowledge as self-care knowledge. According to Erickson et al., (1983) all individuals
have internal and external self-care resources. Internal self-care resources are personal
strengths (self-strengths) that a person can use to promote health and growth. The MRM
theory emphasizes that these strengths must be defined by the perceptions of both the
nurse and the client and can include values, attitudes, endurance, patterns, or any other
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qualities that can be perceived as a personal strength and resource of that individual. External self-care resources include the client’s social support and network
systems. The social network includes people with whom the person is socially acquainted
with, and support systems are people who are perceived to support, and provide resources
for the person. Using both internal and external resources, the nurse can assist the client
to achieve, and promote an optimal level of holistic health (Erickson, et al., 1983).
The MRM theory also notes that for individuals to be able to maximize the full
potential of their resources, they must have their needs met in accordance with Maslow’s
hierarchy of needs. According to Maslow (1943), human needs are organized in a
hierarchy as physiologic needs, safety and security needs, love and belonging needs, self-
esteem needs, and self-actualization needs. More basic needs must be met prior to
meeting higher level needs. The higher the level of needs met, the greater the ability an
individual has to cope appropriately with stress and ill health and the easier it is for them
to achieve equilibrium. People whose high-level needs are unmet are not able to mobilize
resources when they are faced with stress/illness. A nurse, with full knowledge of what
the clients’ perceived needs are, is able to provide holistic care by designing nursing
interventions that will help the client meet their physiological, psychological, social,
cognitive, and spiritual needs according to what the client perceives as the most important
need.
Modeling and role-modeling involves both the patient and the nurse. Schultz
(2004) describes the concept of modeling as a central concept whereby each individual
needs to develop an understanding of the other person’s world within the other person’s
framework and perspectives, while suspending one’s own opinions, values, and
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perceptions. Therefore, the nurse using this theory places herself/himself in the patient’s
view point and sees the world through the patient’s eyes. When individuals see the world
through another person’s eyes, they are able to build relationships based on mutual
respect and from a more neutral starting point (Schultz, 2004).
The MRM theory requires the health care professional to understand the patient’s
perspective regarding his/her health problem. Nurses do not make assumptions and
decide on what they think a patient’s needs are, but rather listen to the patient and
prioritize interventions depending on what the client thinks is most important.
Even though this theory is often used to refer to the nurse-patient relationship,
Schultz (2004) points out that the theory essentially describes human relationships. For
purposes of this study, the theory will be adapted to explain the human relationship of
nurse leaders and mental health nurses in the context of reducing and preventing burnout.
Summary
This chapter has provided and discussed the rationale for the literature review and
the significance of addressing the issue of burnout among mental health nurses.
Protecting nurses from burnout is important because when nurses are healthy and
function at the top of their professional expectations, they are motivated to work
diligently, which leads to better nursing care and consequently good patient outcomes.
The theory of Modeling and Role-Modeling was introduced and discussed as a
conceptual framework for the literature review.
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Chapter Two: Methods
This chapter will review the search strategies for the literature review on the nurse
leader effect on burnout among mental health nurses working in inpatient psychiatry.
The criteria for including and excluding research studies as well as the criteria for
evaluating the research studies will be presented. The number and type of research
studies will also be specified.
Search Strategies
The search strategy used to identify research studies for this literature review
include the databases, MEDLINE (2006 to 2017), CINAHL (2006 to 2017), PsycINFO
(2006 to 2017) and PsycARTICLES (2006 to 2017). Search terms used were: Psychiatric
Nur*, Mental Health Nur*, Mental Health Professional*, Mental Health Staff, Mental
Health Personnel, and Behavioral Health Nur*. These search terms were combined with
the terms stress, burnout, coping, job satisfaction, stress management, leadership,
management and administration.
Criteria for Including or Excluding Research Studies
To be included in the review, the research studies had to be written in English,
published between 2006 and 2017, pertain to mental health nurses and are related to
burnout and nursing leadership. Papers not written in English, literature reviews and
commentaries were excluded.
Employing the above search strategy, more than 100 articles were initially
identified and saved. All the articles were current in terms of the timeline specified
except for those that were needed to give historical perspectives on burnout and those on
the Modeling and Role Modeling theory. The articles were then reviewed to identify
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those studies that specifically explored burnout on inpatient psychiatry units in hospital
settings. The search was narrowed further to select only studies that were conducted on
inpatient psychiatry and had looked at nursing leadership’s role in mitigating mental
health nurses’ burnout rates.
Number and Types of Studies for the Review
For this critical review of the literature project, twenty studies were reviewed. The
articles were selected and included in the matrix either because they specifically
addressed the role of nursing leadership involvement on burnout among nurses working
in mental health or their findings could be generalized to mental health nurses.
The studies reviewed employed a variety of research designs and ten articles had
a qualitative descriptive design. Seven articles represented cross-sectional observational
designs and two of them were descriptive quantitative studies. Only one study used a
quasi-experimental design. The studies chosen were conducted in different parts of the
world including, South Africa, Cyprus, United Kingdom, USA, Canada, China, Finland,
Ireland, and Jordan and as such, provide a comprehensive picture on the effects of
burnout in inpatient psychiatry and the impact of nursing leadership on ameliorating the
levels of burnout among mental health nurses.
Criteria for Evaluating Research Studies
This literature review project aimed to find the highest level of scientific evidence
to support the research question. The Johns Hopkins Research Evidence Appraisal Tool
as well as the Johns Hopkins Non-Research Evidence Appraisal Tool (Dearholt & Dang,
2012), were used to evaluate the strength of the research evidence. Using the Matrix
method (Dearholt & Dang, 2012), each research article was evaluated with six topics:
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Citation/Level and Quality, Purpose, Sample/Setting, Design, Results/Conclusion, and
Recommendations. All the research studies were evaluated for their strength before being
included in the literature review. Only the research studies with high levels of scientific
evidence were used.
Summary
The research studies chosen for the review were representative of nurse
populations from different parts of the world. They are a testament of the widespread
nature of burnout among nurses in many parts of the world. The Johns Hopkins Evidence
Appraisal Tool used to evaluate the evidence ensured that only studies that had strong
research evidence were included in the review. The studies selected were of high quality
and sufficiently provided the needed data.
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Chapter Three: Literature Review and Analysis
This chapter includes a review and analysis of the articles that fit the inclusion
criteria. The reviewed studies are presented in an evidence matrix using these topics:
Citation/Level and Quality, Purpose, Sample/Setting, Design, Results/Conclusion, and
Recommendations. The level and quality of the articles were determined using the Johns
Hopkins Evidence Level and Quality Guide (Dearholt & Dang, 2012). This chapter will
provide a synthesis of the findings as well as a critique of the strengths and weaknesses of
the salient studies.
Synthesis of Major Findings
Throughout the literature reviewed, the authors indicate that there is evidence to
support burnout in the nursing profession (Dickson &Wright, 2008; Hoge, et al., 2007).
While there are many different factors that contribute to the prevention and reduction of
nurse burnout among mental health nurses, this review of the literature specifically
intends to find out what the literature indicates regarding the effect of nursing leadership
involvement on the units and burnout among mental health nurses.
Leader - Nurse Communication and Burnout
Mental health nursing relies on communication and relationship building as the
core of its clinical practice (Peplau, 1997; Ennis, Happell, Broadbent and Reid-Searl,
2013). Nurses rely on therapeutic communication to establish rapport with patients and
also to communicate important transfer of care communication with each other and other
providers. Ennis et al. (2013) found that communication has particular relevance for
clinical leaders in mental health nursing. In their study on the importance of
communication for clinical leaders in mental health nursing, Ennis et al. (2013) found
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that clinical leaders in the mental health specialty are nurses with the ability to
communicate effectively and influence others in the clinical setting. They identified
leader attributes of communication like choice of language, nonverbal communication,
and listening as being important communication skills that mental health leaders need to
possess and practice in their day-to-day interactions with nurses to enable them to have
this influence. Findings by Ennis et al. (2013) also found that the nurse leaders that were
thought to be effective clinical leaders by nurses working in mental health were those
with an ability to communicate with others in a way that builds effective working
relationships and rapport. Hanrahan et al. (2010) identified the importance of leadership
presence and availability in the context of open communication and sharing information
with staff nurses as major predictors of psychiatric nurse burnout reduction. Nurses
appreciate the opportunity to participate in policy decisions that affect them, being
acknowledged publicly for their work, being heard, as well as getting answers to their
questions in a timely manner. According to Edwards et al., (2006), the nurse’s ability to
discuss sensitive and confidential issues with their supervisors was found to have positive
association with lower levels of burnout.
Clinical Supervision and Burnout
Nurse leaders when available on the unit have the opportunity to provide clinical
supervision to the nurses. Gonge and Buus (2011) who defined clinical supervision as an
activity that allows nursing staff to reflect on their clinical practice under the guidance of
a supervisor, found that this kind of supervision is beneficial for psychiatric nursing staff
and that it improves their quality of care, coping, job satisfaction and can lead to less
stress, emotional exhaustion, and depersonalization. This in effect contributes to lower
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levels of burnout (Gonge & Buus, 2011). Rice et al. (2007) on reviewing the supervisor’s
perspective found that the supervisors thought that provision of clinical supervision
improves staff morale and motivation and provides an avenue for the supervisor to
review the nurse’s clinical practice and evaluate their professional and personal
development. This allows the nurse leaders to identify gaps in individual nurse’s practice
and provide resources and interventions for growth and hence promote job satisfaction
(Rice et al., 2007)
In 2006, Edwards et al. studied the role of clinical supervision and its influence on
burnout levels in Welsh community mental health nurses. Surveys and demographic
questionnaires were given to a sample of 817 community mental health nurses and there
were 260 respondents. Both the Maslach Burnout Inventory (MBI) and the Manchester
Clinical Supervision Scale (MCSS) were used in this study. This study found that higher
scores on the MCSS were associated with lower levels of burnout, implying that if
clinical supervision is seen as effective, then the community mental health nurses
surveyed were more likely to report lower levels of emotional exhaustion and
depersonalization (Edwards et al., 2006). Results from this study also showed that if
nurses felt supported by their supervisor and that if they had a positive attitude towards
clinical supervision this could also lead to lower levels of burnout for depersonalization
(Edwards et al., 2006).
Sherring and Knight (2009) in their study on burnout among city mental health
nurses found that nurses who feel supported and valued have lower levels of burnout.
However, their study also found that for nurses to benefit from nurse leaders, they have to
perceive that the supervision they receive is adequate. A study by Koivu, Saarinen and
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Hyrkas (2012) found that nurses who did not find their clinical supervision effective were
inclined to over commit to work, which is common in persons prone to develop burnout
while quality of work increased significantly among the nurses who received effective
clinical supervision. They suggested that efficient clinical supervision could be both an
antecedent as well as a consequence of well-being at work (Koivu, Saarinen, & Hyrkas,
2012). Sherring and Knight (2009) also found that mental health nurses feel supported by
their leaders when they are involved in decision-making and that this helps to reduce
levels of burnout. This finding is supported by a study by Hamaideh (2011) on burnout,
social support, and job satisfaction among Jordanian mental health nurses that concluded
that increasing job satisfaction, and training supervisors to support staff are important
steps in reducing burnout levels.
Clinical supervision enables supervisors to assist nurses reflect on their clinical
practice. Doing this helps identify knowledge and skill gaps and areas that need
improvement and allows supervisors to provide assistance to the nurse. This is important
for mental health nurses as it focuses on the development and refinement of professional
practice and ensures accountability (Gonge & Buus, 2011). This practice also allows the
nurse leader to evaluate the nurse’s skills and ensure they are meeting standards of work,
and errors are detected or prevented ensuring good practice and continuous improvement
in clinical care (Rice et al., 2007).
Psychiatric Work Environment and Burnout
The inpatient psychiatry practice environment is different from other nursing
specialty areas. In psychiatry, many patients are ambulatory and they walk freely in the
common area of the units. Nurses and other care providers interact with each other and
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with patients in these common areas. The atmosphere in the psychiatry work environment
can range from being quiet to suddenly becoming loud as patient behaviors change.
Mentally ill patients can quickly become elevated in mood, become aggressive toward
each other or to care providers. Patient aggression has been described as being a part of
the psychiatry work environment and has been found to be one of the factors that
contribute to burnout among mental health nurses (Bimenyimana, Poggenpoel, Myburgh,
& Van Niekerk, 2009).
Several studies (Bogaert et al., 2013; Hanrahan et al., 2010) identified the
presence of nursing leadership and their availability to the nurses as a factor in assisting
psychiatric nurses to deal with the stress of their work environment. Hanrahan et al.
(2010) in their study on the relationship between psychiatric nurse work environments
and nurse burnout in acute care general hospitals found a strong and significant
relationship between psychiatric nurses’ experiences of feeling valued by their leaders
with lower rates of expressed emotional exhaustion and depersonalization.
Bogaert et al. (2013) in their study on the impacts of unit-level nurse practice
environment and burnout on nurse-reported outcomes in two psychiatric hospitals
identified a positive association between nurse management at the unit level with lower
levels of the burnout. They cautioned that nurse leaders ought to pay attention to peer and
interdisciplinary relations by promoting a model of care that ensures a fair and
meaningful recognition and acknowledgement of good collegial relationships. This
creates an attractive and productive work environment in psychiatric inpatient care units
(Bogaert et al. 2013).
Roche, Duffield and White (2011) in their study on factors in the practice
environment of nurses working in inpatient mental health surveyed 260 mental health
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nurses with a response rate of only 32%. The results from this study showed a positive
relationship between effective clinical supervision and burnout. However, the reduction
in nurse burnout could not be attributed to supervision alone, as other factors in the
practice environment like quality nursing care and opportunities to participate in hospital
affairs might have contributed to decreased level of burnout (Roche, Duffield &White,
2011).
Hanrahan, Aiken, McClaine and Hanlon (2010) studied the relationship between
psychiatric nurse work environments and nurse burnout in acute care nursing. They
concluded that leadership of nurse managers is central to all aspects of the work
environment and to preventing emotional exhaustion and burnout. They suggested that
nurse managers should recognize the strength of the relationship between organizational
factors and psychiatric nurse burnout.
Leadership Style and Burnout
There are many different styles of leadership that are used by nurse leaders.
According to Madathil, Heck and Schuldberg (2014), leadership style and work role
autonomy have been found to be environmental factors that protect against burnout in
nurses. They found that transformational leadership by nurse supervisors may help to
reduce burnout by reducing the impact of depressive symptoms and increasing feelings of
personal accomplishment in psychiatric nurses. Their study found that nurses felt that
transformational leadership helped them feel more valued and was conducive to a positive
work environment which lowered perceived stress and ultimately contributed to less
burnout (Madathil, Heck & Schuldberg, 2014).
25
A study by Kanste, Kyngäs and Nikkil (2007) on the relationship between
multidimensional leadership and burnout among nursing staff found that transformational
leadership can protect nurses from depersonalization. Attributes of transformational
leadership like sharing organizational goals with clear explanation on how nursing tasks
help achieve them, ability to solicit and entertain new ideas, self-management and
adaptability help nurses buy into what the organization is doing and enable them to feel
part of the team as they feel listened to and are aware of the big picture. This study also
found that management by exception protects from depersonalization and increases
personal accomplishment. Active management by exception behavior of the nurse
manager increases personal accomplishment by ensuring that mistakes are corrected early
and employees are proactively mentored and trained, thus becoming better clinicians,
which protects from burnout (Kanste, 2008).
Critiques of Salient Studies
The studies that are salient to the study question have both advantages and
disadvantages. Most of the studies were performed on mental health nurses. All of them
apart from the study by Edwards et al. (2006) which studied the role of clinical
supervision and its influence on burnout levels in Welsh community mental health nurses
were conducted on nurses working in inpatient psychiatry settings. The analyses in the
studies suggest that there is an association between leaders’ involvement on the unit and
psychiatric nurse emotional exhaustion and depersonalization.
A major drawback on the studies by Edwards et al., (2006) and Bogaert et al.
(2012) is that they used the cross-sectional design. Using the cross-sectional design
makes it impossible (Pompili et al., 2006) to confirm causal links between leadership
26
supervision and burnout rates. Even though the analyses in the study by Edward et al.,
(2006) indicated there was an association between the level of supervision and
psychiatric nurse emotional exhaustion and depersonalization other variables like
personal characteristics of the nurse or patient to nurse staffing ratios among others could
be ruled out. The cross-sectional survey data used in the study has also been criticized
because it only limited the study to a point in time (Edward et al., 2006).
The study by Bogaert et al. (2013) studied psychiatric nursing units in only two
hospitals. The low response rate of the study by Roche, Duffield and White (2011) at
32% made it difficult to be certain that the responses received were representative of the
total sample. When sample size is too small, it is difficult to generalize the findings.
Summary
This chapter looked at the selected studies and synthesized the research in light of
the impact nursing leadership involvement can have on burnout among mental health
nurses. This literature review provided evidence that burnout is a real phenomenon in
many different nursing specialties. Nurses in psychiatry units, because of their unit
layouts and ambulatory patients who can be unpredictable and aggressive, have to work
together as a cohesive team and manage the environment together not only for patient
safety, but for staff safety as well. Communication is therefore important both when
working with patients as well as when collaborating with coworkers. The nurse leaders
are instrumental in facilitating the management of the work environment as well as
enhancing communication among nurses and other providers. The research reviewed
showed that nurse leaders, when involved in inpatient psychiatry units, are able to
27
provide resources, facilitate communication, and provide support and clinical supervision
for the nurses to protect mental health nurses against burnout.
Literature Matrix
Citation/level & Quality
Purpose Sample/Setting Design Results/ Conclusion
Recommendations Methodology Measurement
Bimenyimana, E., Poggenpoel, M., Myburgh, C., & van Niekerk, V. (2009). The lived experience by psychiatric nurses of aggression and violence from patients in a Gauteng psychiatric institution. Curationis, 32(3), 4-13 10p. doi:10.4102/curations. v32i3.1218
Level: - III
Quality: - Good
To explore and describe the lived experiences by psychiatric nurses of aggression and violence from patients in a Gauteng psychiatric institution and to describe guidelines to assist the psychiatric nurses to manage patient aggression and violence in the psychiatric institution.
A purposive sample of psychiatric nurses in Gauteng psychiatric institution in South Africa, was utilized. All the participants were registered psychiatric nurses who had been working in the institution at least for the last two years. Out of ten participants, five were males and five were females all aged between twenty and forty years old.
A qualitative, descriptive and contextual research design was utilized.
One- on-one interviews were conducted with participants until saturation
-Aggression and violence toward psychiatric nurses by the mentally ill patients is real
-Nurses experience physical, verbal and emotional assault.
-As a result of this violence, many nurses are leaving the profession.
-The nurses feel unsupported and burnout is common.
- A holistic view of addressing patient aggression to help the nurses work with patient population - A proactive support for the nurses to help in management of negative feelings - Nurses need assistance in management of aggression from patients and coping with stress. -Future studies on the impact of violence and aggression on the professional and personal lives of the psychiatric nurses.
28
Citation/level & Quality
Purpose Sample/ Setting
Design Results/ conclusion
Recommendations Methodology Measurement
Edwards, D., Burnard, P., Hannigan, B., Cooper, L., Adams, J., Juggessur, T., & ... Coyle, D. (2006). Clinical supervision and burnout: The influence of clinical supervision for community mental health nurses. Journal of Clinical Nursing, 15(8), 1007-1015 9p. doi:10.1111/j.1365- 2702.2006.01370.x
Level: - III
Quality: - Good
To establish the degree to which clinical supervision might influence levels of reported burnout in community mental health nurses in Wales, UK.
260 community mental health nurses in Wales, UK
The mean age was 42 years (range 25–64)
62% were women.
Descriptive Qualitative design.
Surveys were used
Maslach Burnout Inventory and Manchester Clinical Supervision Scale were used to collect data
-Only 32%of the original sample completed the survey.
-There was a positive relationship between effective clinical supervision and burnout.
-The findings from this study suggested that if clinical supervision is effective then community mental health nurses experience lower levels of burnout.
-Further research is required to determine the long-term benefits of implementing clinical supervision
- Further research to determine what other factors have an influence on levels of burnout for this group of nurses over an extended period of time.
29
Citation/level & Quality
Purpose Sample/ Setting
Design Results/ Conclusion
Recommendations Methodology Measurement
Ennis, G., Happell, B., Broadbent, M., & Reid-Searl, K. (2013). The importance of communication for clinical leaders in mental health nursing: The perspective of nurses working in mental health. Issues in Mental Health Nursing, 34(11), 814-819 6p. doi:10.3109/01612 840.2013.829539
To describe the views of nurses working in mental health about the importance of effective communication in a day to day clinical leadership.
Registered nurses practicing in a mental health setting who had worked in the service for at least 12 months.
Qualitative study This study was conducted using a grounded theory approach
Individual semi-structured interviews, recorded on a digital voice recorder, and later transcribed verbatim were used.
-Communication is an attribute of effective clinical leadership for nurses working in a mental health setting.
-Further research is needed on the development of evidence-based knowledge on the attributes of clinical leader in mental health nursing
Level: - III
Quality: - Good
30
Citation/level & Quality
Purpose Sample/Setting Design Results/ Conclusion
Recommendations Methodology Measurement
Karanikola, M. K., & Papathanassoglou, E. D. (2013). Exploration of the burnout syndrome occurrence among mental health nurses in Cyprus. Archives of Psychiatric Nursing, 27(6), 319- 326 8p. doi:10.1016/j.apnu.20 13.08.004
Level: - III
Quality: - Good
To explore the levels of burnout and associations with anxiety and depressive symptoms among psychiatric– mental health nurses in Cyprus
Registered psychiatric mental health nurses with bachelor's degree employed in adult and child/adolescent hospital and community mental health services in the public sector in the Greek-Cypriot area of Cyprus A sample of 226 nurses was used
A quantitative study.
A descriptive correlational design with cross-sectional comparisons was applied through self-reported questionnaires Measurements used were, Maslach Burnout Inventory, Hamilton Anxiety Scale and the Beck's Depression Inventory
- The study found an association between burnout, anxiety and depressive symptoms in psychiatric mental health nurses.
-Psychiatric mental health nurses are at an increased risk of stress- related physiological disturbances
-Future studies to determine whether or not a causative relationship between burnout and anxiety and depressive symptoms exists.
-The study recommends empowering nurses and strengthening the relationship between the nurses and supervisors and with hospital administration.
31
Citation/level & Quality
Purpose Sample/ Setting
Design Results/ Conclusion
Recommendations Methodology Measurement
Sherring, S., & Knight, D. (2009). An exploration of burnout among city mental health nurses. British Journal of Nursing, 18(20), 1234-1240 7p. doi:10.12968/bjon.20 09.18.20.45114
Level: - III
Quality: - Good
To describe burnout among mental health nurses working at a city National Health Services Trust in the UK and to develop an understanding of the variables involved in burnout for mental health nurses
A population sample of all qualified mental health nurses working at the Trust was recruited. A total of 475 nurses
A qualitative study. A survey design was used.
The survey incorporated the Maslach Burnout Inventory (MBI)
-Nurses who have higher-level academic qualifications and feel supported and valued at work have lower levels of burnout.
-The quality and frequency of clinical supervision decreases the level of burnout experienced.
-Reducing burnout could produce cost savings and improve patient care.
-Further research on burnout among mental health nurses is needed to help find ways to lower the risk of burnout.
-Further research should also be conducted into the relationship between burnout and academic qualifications
-More research to uncover the impact of clinical supervision in supporting and valuing mental health nurses, and involving them in decision making
32
Citation/level & Quality
Purpose Sample / Setting
Design Results/ Conclusion
Recommendations
Methodology Measurement
Koivu, A., Saarinen, P. I., & Hyrkas, K. (2012). Does clinical supervision promote medical– surgical nurses' well-being at work? A quasi- experimental 4-year follow-up study. Journal of Nursing Management, 20(3), 401-413. doi:10.1111/j.1365- 2834.2012.01388.x
Level: II
Quality: Good
The aim of the study was to examine the effectiveness of Clinical supervision (CS) in medical- surgical nursing by exploring the effects of CS on psychosocial risk/protective factors shown to be of importance to nurses’ well- being and health outcomes.
Setting - Medical and Surgical units of a Finnish university Hospital.
Sample - Female registered nurses and nursing assistants working in 5 medical and 9 surgical units of the hospital. Altogether 84 nurses
A quasi- experimental design
-Questionnaire surveys were used
- The Nordic Questionnaire for Psychological and Social Factors at Work (QPSNordic)
- Self-rated health (SRH) - Maslach Burnout Inventory–General Survey (MBI–GS) - General Health Questionnaire (GHQ-12) - The Finnish version of the Manchester Clinical Supervision Scale (MCSS)
- Perceptions of support from superiors, the fairness of leadership and the human resource primacy of the organization improved among those nurses who reported effective CS, and their intrinsic work motivation remained on a higher level than that of other nurses - The nurses who did not find their CS effective were inclined to over commitment to work, which is common in persons prone to develop burnout and related health problems - Quality of work increased significantly among the nurses who attended effective CS, whereas it decreased among other nurses. - Perceptions of autonomy and professional efficacy increased among those nurses who attended effective CS, whereas these perceptions decreased among the other nurses
- To sustain nurses’ well- being at work, nurse managers need to develop a learning organization in the workplace by using clinical supervision
- Research is needed to find out measures that promote and evaluate CS in health care organizations
33
Citation/level & Quality
Purpose Sample/ Setting
Design Results/ Conclusion
Recommendations Methodology Measurement
Alsaraireh, F., Quinn Griffin, M. T., Ziehm, S. R., & Fitzpatrick, J. J. (2014). Job satisfaction and turnover intention among Jordanian nurses in psychiatric units. International Journal of Mental Health Nursing, 23(5), 460-467 8p. doi:10.1111/inm.1207 0
Level - III
Quality – Good
The purpose of this study was to examine the relationship between job satisfaction and turnover intention among Jordanian nurses in the psychiatric units of the Jordanian National Mental Health Center.
- A governmental hospital for mental health in Jordan. - The hospital has 250 beds, 200 nurses, and more than 30 outpatient clinics. -179 nurses met the inclusion criteria
Quantitative study, with a Descriptive, Cross- sectional design.
- The Minnesota Job Satisfaction Questionnaire (MSQ) was used to measure job satisfaction
- -Withdrawal Cognition Scale (WCS) was used to measure nurse turn over
- Job satisfaction was found to be negatively related to turnover intention. - Personal characteristics have important influences on nurses’ job satisfaction and turnover intention. - Higher job satisfaction among female nurses and married nurses, and lower job satisfaction among male nurses and single nurses. - Nurses with higher education had higher intensions of leaving - Administrative interventions are needed to improve quality of work
- More research to provide a better understanding of factors influencing nurses’ stress and job satisfaction in mental health nursing and to identify strategies to improve working might allow conditions - Research on education and training programs about risk management and prevention of violence on nurses
34
Citation/level & Quality
Purpose Sample/ Setting
Design Results/ Conclusion
Recommendations Methodology Measurement
Furtado, L. R., Batista, M. C., & Silva, F. F. (2011). Leadership's impact in turnover and career abandonment intention: The Azorean hospital nurses case. Hospital Topics, 89(3), 51-58. doi:10.1080/0018586 8.2011.596797
Level: III
To identify the manager’s leadership behavior and to determine it had an impact on turnover and career abandonment intentions among nurses
Setting- Two public hospitals
Sample – All nurses except those working in the OR and OPD. A total of 266 nurses (22 head nurses and 244 staff nurses)
Prospective descriptive and inferential study.
- Questionnaires were used
- Nursing leadership is important in staff nurse retention
- private hospitals have higher nurse retention
- Excessive nurse turnover is costly for hospitals
- Hospitals need to provide incentives including better wages and good working conditions for nurses
- Staff nurses need support in enhancing both individual and professional development.
- Nurse managers need training in meeting the needs of their nurses
Quality: Good - Nurse turnover has negative implications for patients
- Organizational commitment and economic fact impact nurse retention.
35
Citation/level & Quality
Purpose Sample/ Setting
Design Results/ Conclusion
Recommendations Methodology Measurement
Hanrahan, N., Aiken, L., McClaine, L., & Hanlon, A. (2010). Relationship between psychiatric nurse work environments and nurse burnout in acute care general hospitals. Issues in Mental Health Nursing, 31(3), 198-207 10p. doi:10.3109/016128 40903200068
Level: III
Quality: Good
- To examine the extent to which organizational factors of the inpatient psychiatric environments are associated with psychiatric nurse burnout.
- 67 hospitals all members of the American Hospital Association (AHA)
- Psychiatric Nurse Sample (n = 353)
- Cross-sectional observational design
- A secondary analysis linked nurse survey data
- Hospital data
- Better nurse practice work environments and lower psychiatric nurse reports of emotional exhaustion and depersonalization - Changes in the quality of the nurse practice environment improves psychiatric nurse job satisfaction, and leads to better patient outcomes - Hospital administrators and nurse managers should recognize the strength of the relationship between organizational factors and psychiatric nurse burnout. - leadership of managers is central to all aspects of the work environment and to preventing burnout emotional
- Nurse leaders can modify some organizational factors including valuing the contribution of nurses, - Nurses should be engaged in active quality improvement programs Nurse managers should be skilled in recognizing and addressing problems that indicate riffs in nurse and physician collaboration, and providing adequate psychiatric nurse staffing and thus prevent burnout. - Future research is needed to explore impact of inpatient psychiatric care environments and patient outcomes
36
Citation/level & Quality
Purpose
Sample/ Setting
Design Results/ Conclusion
Recommendations Methodology Measurement
Madathil, R., Heck, N. C., & Schuldberg, D. (2014). Burnout in psychiatric nursing: Examining the interplay of autonomy, leadership style, and depressive symptoms. Archives of Psychiatric Nursing, 28(3), 160-166 7p. doi:10.1016/j.apnu. 2014.01.002
Level: III
Quality: Good
To examine the relationships between leadership style of psychiatric nurse supervisors, work role autonomy, and psychological distress in relation to psychiatric nurse burnout
- Eighty-nine psychiatric nurses from Montana and New York hospitals
Quantitative study - Descriptive cross-sectional design.
- The Maslach Burnout Inventory-Human Services Survey
- Demographic questionnaire
- Multifactor Leadership Questionnaire
- Nursing Work Index
- Brief Symptom Inventory
- Leadership style and work role autonomy were found to be environmental factors that protect against burnout in nurses
- The relationship between depressive symptoms and the burnout component of personal accomplishment is influenced by nurses’ perceptions of the leadership style in their work environment
- nurse supervisor leadership styles are a possible environmental protective factor
- Transformational leadership by nurse supervisors may help to reduce burnout while also reducing the impact of depressive symptoms on feelings of personal accomplishment in psychiatric nurses.
- Future research is needed to find out if there is an association between nurse supervisor leadership style and decrease in rates of nurse burnout and turnover.
37
Citation/level & Quality
Purpose Sample/ Setting
Design Results/ conclusion
Recommendations Methodology Measurement
Hamaideh, S. H. (2011). Burnout, social support, and job satisfaction among Jordanian mental health nurses. Mental Health Nursing, 32:234–242. doi: 10.3109/01612840.20 10.546494
Level: III
Quality: Good
To measure the levels of burnout and identify the correlates of burnout among Jordanian mental health nurses.
The target population was Jordanian nurses working in mental health care settings in Jordan. 220 were invited to participate.
Descriptive correlational cross- sectional design
The Maslach Burnout Inventory (MBI). The Social Support Scale (SSS). The Job Satisfaction Scale (JSS)
- Nurses with high levels of burnout are more likely to leave their job. -Improving working conditions, ensures a safe working environment. - Increasing job satisfaction, and training supervisors to support staff are important steps in reducing burnout levels.
-Improvement of the psychosocial work environment among mental health nurses.
- Increase continuing education programs for nurses, especially in stress management, coping skills, and personal skills and accomplishments, and those that update knowledge.
-Supervisors should help minimize conflicting tasks and provide advice and support for non-work issues.
38
Citation/level & Quality
Purpose Sample/ Setting
Design Results/ conclusion
Recommendations Methodology Measurement
Long, C. G., Harding, S., Payne, K., & Collins, L. (2014). Nursing and health-care assistant experience of supervision in a medium secure psychiatric service for women: Implications for service development. Journal of Psychiatric & Mental Health Nursing, 21(2), 154-162. doi:10.1111/jpm.12066
Level: III
Quality: Good
The study examined the perceived benefits, the best practice elements and the practical aspects of clinical supervision including how to improve practice.
128 nurses (46 RNs and 81 Health Care Assistants) The women’s service of an independent charitable trust hospital with a pathway of care from medium security through to low security to open mental health settings was used
Questionnaire surveys -Secure Unit Supervision Questionnaire (SUSQ)
-Supervision Audit Questionnaire
-Partnership Questionnaire for Supervision
-The Bradford Clinical Supervision Scale
-Staff are motivated by and feel positive about clinical supervision (CS) -There is a widespread lack of knowledge about CS - Education and training on the purpose and practice of CS is needed. -Motivated staff play a major role in communication strategy to inform and motivate other staff
- Securing organizational and management support and agreement to commit the necessary resources.
- Developing and operationalizing a strategic plan for CS
- Integrity monitoring and evaluation
39
Citation/level & Quality
Purpose Sample/ Setting
Design Results/ conclusion
Recommendations Methodology Measurement
Kanste, O., Kyngäs, H., & Nikkil, J. (2007). The relationship between multidimensional leadership and burnout among nursing staff. Journal of Nursing Management, 15(7), 731-739. doi:10.1111/j.1365- 2934.2006.00741.x
Level: III
Quality: Good
To explore the relationship between multi- dimensional leadership and burnout among nursing staff.
601 nurses and nurse managers working in different health care organizations around Finland.
Non-experimental survey design
-Multifactor Leadership Questionnaire (MLQ) - Maslach Burnout Inventory- Human Services Survey (MBI- HSS)
-Rewarding transformational leadership can protect nurses from depersonalization. -Management-by- exception protects from depersonalization and increases personal accomplishment.
-It is recommended that nurse managers need training on how to give their staff adequate feedback about performance, social support, individualized consideration and encouragement to develop know-how. -The study suggests that interventions aimed at preventing or reducing burnout need to focus on the leadership behavior of the nurse manager.
40
Citation/level & Quality
Purpose Sample/ Setting
Design Results/ Conclusion
Recommendations Methodology Measurement
Laschinger, H. K. S., Labatt, A., Borgogni, L., Consiglio, C., Read, E. (2015). The effects of authentic leadership, six areas of worklife, and occupational coping self-efficacy on new graduate nurses’ burnout and mental health: A cross- sectional study. International Journal of Nursing Studies 52 (5) 1080–1089. doi.org/10.1016/j.ijnu rstu.2015.03.002
To test a model linking authentic leadership, areas of work life, occupational coping self- efficacy, burnout, and mental health among new graduate nurses.
New graduate nurses with less than 3 years of nursing experience working in direct patient care settings. 1009 new nurses from across Canada
-Cross-sectional study. Standardized questionnaires - General Health Questionnaire - Maslach Burnout Inventory-General Survey - Authentic Leadership Questionnaire - Areas of Worklife Scale - Occupational Coping Self-Efficacy scale
-Burnout is an occupational hazard that has detrimental effects on the mental health of new graduate nurses. – Burnout threatens retention of new graduate nurses in mental health nursing.
- Leaders need to play an important role in strengthening new nurses’ confidence in their ability to cope with the demands of their jobs. - Leaders should protect nurses from burnout development and poor mental health. - Leadership training is needed to develop supervisors’ authentic leadership skills.
Level: III
Quality: Good
41
Citation/level & Quality
Purpose Sample/ Setting
Design Results/ conclusion
Recommendations Methodology Measurement
Bowers, L., Nijman, H., Simpson, A., & Jones, J. (2011). The relationship between leadership, team working, structure, burnout and attitude to patients on acute psychiatric wards. Social Psychiatry & Psychiatric Epidemiology, 46(2), 143-148. doi:10.1007/s00127- 010-0180-8
Level: III
Quality: Good
To understand the relationship between leadership, team working, structure, burnout and attitude to patients on acute psychiatric wards, and assess how that relates to rates of conflict and containment.
136 acute psychiatric wards with their staff in 26 NHS Trusts in England,
Multivariate cross-sectional design. Questionnaires were used.
-The Attitude to Personality Disorder Questionnaire (APDQ) -Ward Atmosphere Scale (WAS) - Team Climate Inventory (TCI) -Multifactor Leadership Questionnaire (MLQ) -Maslach Burnout Inventory (MBI).
-Overall performance of staff teams is associated with differing rates of containment onwards. -Interventions to reduce rates of containment on wards may need to address staff issues at every level, from leadership through to staff attitudes.
-To assist wards in establishing and maintaining an effective structure for patients, will require an intervention that enhances leadership and supports and builds the ward team and its functioning. -Leadership training for the ward manager. -Team building interventions for the team. -Ward rule and routine clarification and agreement to strengthen structure. -Clinical supervision to reduce burnout and enhance positive attitudes to difficult patients.
42
Citation/level & Quality
Purpose Sample/ Setting
Design Results/ Conclusion
Recommendations Methodology Measurement
Kanste, O. (2008). The association between leadership behavior and burnout among nursing personnel in health care. Nordic Journal of Nursing Research, 28(3), 4 -8. doi:10.1177/0107408 30802800302
To explore the association between leadership behavior and burnout among nursing personnel in health care
900 nurses and nurse managers in various health care organizations around Finland
Surveys -Multifactor Leadership Questionnaire (MLQ)
-Maslach Burnout Inventory-Human Services Survey (MBI-HSS).
-Nursing leadership is both positively and negatively associated with burnout among nursing personnel.
- Active management- by-exception behavior of the nurse manager may increase personal accomplishment.
-Active and future- oriented transformational leadership and rewarding subordinates seem to protect from burnout. - Forward-looking transformational nurse manager are essential in successful nursing leadership
Level: III
Quality: Good
-Passive management-by- exception and laissez- faire leadership were positively related to emotional exhaustion and depersonalization, while the connection to personal accomplishment was negative
-Traditional leadership behavior such as rewarding and active monitoring of work performance is still needed in nursing.
43
Citation/level & Quality
Purpose Sample/ Setting
Design Results/ Conclusion
Recommendations Methodology Measurement
Koivu, A., Saarinen, P. I., & Hyrkas, K. (2012). Who benefits from clinical supervision and how? The association between clinical supervision and the work-related well- being of female hospital nurses. Journal of Clinical Nursing, 21(17-18), 2567-2578. doi:10.1111/j.1365- 2702.2011.04041.x
Level: III
To identify which nurses benefitted from clinical supervision and explore whether they were healthier and more satisfied with their work than their peers who did not attend clinical supervision
304 female hospital nurses working in medical and surgical units in Finland
Survey - Manchester Clinical Supervision Scale (MCSS)
- Nordic Questionnaire for Psychological and Social Factors at Work (QPSNordic)
- General Health Questionnaire (GHQ-12)
-Clinical supervision is job associated with job and personal resources that promote well-being at work.
-Efficient clinical supervision is probably both an antecedent as well as a consequence of well-being at work.
-Management planning to provide formal support for health care providers.
-Reflecting on practice in clinical supervision generates new ideas about how to improve the quality of care and the psychosocial work environment.
-Clinical supervision may be viewed as a preventive method rather than a treatment for burnout.
Quality: Good
44
Citation/level & Quality
Purpose Sample/ Setting
Design Results/ conclusion
Recommendations Methodology Measurement
Shi, R., Zhang, S., Xu, H., Liu, X., & Miao, D. (2015). Regulatory focus and burnout in nurses: The mediating effect of perception of transformational leadership. International journal of nursing practice, 21(6), 858-867. doi:10.1111/ijn.12315
Level: III
Quality: Good
To examine the relationship between a group of Chinese nurses’ regulatory focus and their burnout, as mediated by their perceptions of transformational leadership.
The sample was heterogeneous and included nurses in a variety of roles, age groups, and levels of education and seniority in hospitals in western China. (n=378)
Correlational study using a cross-sectional design.
-General Regulatory Focus Measure (GRFM) - Transformational Leadership Inventory (TLI). - Maslach Burnout Inventory—General Survey (MBI-GS)
-Promotion- and prevention- focused individuals benefit asymmetrically from perceived transformational leadership. - Promotion- focused individuals benefit from a perceived transformational leadership. -
- Occupational health can be promoted by encouraging nurses and their managers to adopt promotion-focused tactics when pursuing goals.
-Leaders should pay attention to the individuals nurse’s regulatory focus. - Nurse managers can amplify nurses’ sensitivity to transformational leadership and improve nurses’ well-being and optimize patient outcomes.
45
Citation/level & Quality
Purpose Sample/ Setting
Design Results/ conclusion
Recommendations Methodology Measurement
Gonge, H., & Buus, N. (2011). Model for investigating the benefits of clinical supervision in psychiatric nursing: A survey study. International Journal of Mental Health Nursing, 20(2), 102- 111. doi:10.1111/j.1447- 0349.2010.00717.x
Level: III
Quality: Good
To test a model for analyzing the possible benefits of clinical supervision in psychiatry nursing
136 nursing staff members in permanent employment on nine general psychiatric wards and at four community mental health centers at a Danish psychiatric university hospital.
-Cross-sectional questionnaire survey.
-Manchester Clinical Supervision Scale (MCSS)
- Participation in clinical supervision was associated with effectiveness, and effectiveness was significantly associated with benefits in terms of increased job satisfaction, vitality, rational coping and less stress, emotional exhaustion, and depersonalization.
- Mediation of benefits of clinical supervision might be enhanced though efforts to ensure frequent participation.
46
Citation/level & Quality
Purpose Sample/ Setting
Design Results/ conclusion
Recommendations Methodology Measurement
Van Bogaert, P., Clarke, S., Willems, R., & Mondelaers, M. (2013). Nurse practice environment, workload, burnout, job outcomes, and quality of care in Psychiatric hospitals: A structural equation model approach. Journal of Advanced Nursing, 69(7), 1515-1524. doi:10.1111/jan.12010
Level: III
Quality: Good
To study relationships between nurse practice environment, workload, burnout, job outcomes and nurse- reported quality of care in psychiatric hospital staff.
357 registered nurses, licensed practical nurses, and non- registered caregivers from two psychiatric hospitals in Belgium between December 2010 - April 2011.
A cross-sectional design with a survey.
-Nurse–physician relationship and other organizational dimensions such as nursing and hospital management were closely associated with perceptions of workload and with burnout and job satisfaction, turnover intentions, and nurse-reported quality of care.
- Studies to explore mechanisms linking the psychiatry nursing environment and burnout and other variables and what differences exist across settings
-Nurse managers need to pay attention to the work environment in relation to workload, quality of care, job outcomes and burnout among nurses.
47
48
Chapter Four: Discussion, Implications, and Conclusions
This chapter will discuss the literature findings in the light of the research project:
nurse leader effect on burnout among mental health nurses. Historical and current trends
and gaps in the literature will be highlighted, as well as implications and
recommendations for nursing research suggested. The theory of Modeling and Role-
modeling will be discussed as a framework for the literature review.
This critical review of the literature has found that the presence of nurse leaders
on the psychiatric units does help in reducing and preventing burnout among mental
health nurses (Bogaert et al., 2013; Hanrahan et al., 2010; Kanste, Kyngäs & Nikkil,
2007). The findings in the literature reviewed are helpful in highlighting specific
competencies of nurse leaders in psychiatry as well as identifying areas that need further
research.
Current Trends and Gaps in the Literature
The review did not find many research studies conducted in the United States
specifically looking at the factors that contribute to burnout in psychiatric nursing.
However, research conducted outside the United States indicates that psychiatric nurses
exhibit higher levels of burnout than nurses in other specialties (Pompili et al., 2006;
Sahraian et al., 2008).
Current trends in mental health services include deinstitutionalization of mentally
ill patients. Inpatient psychiatric services have been moved from state institutions to
general hospitals where patients receive care for acute illness and are then transitioned
into the community where they continue to receive outpatient mental health treatment
49
services. National hospital data indicate growing problems with overcrowding of
inpatient psychiatric units and high patient turnover as well as an increase in episodes of
aggression from patients who would have been better placed in state hospitals (National
Association of Psychiatric Health Systems [NAPHS], 2006). There are also reports of
adverse events including, staff injuries, medication errors, and nurse burnout in inpatient
psychiatric units (Rothschild et al., 2007). A shortage of mental health nurses makes
these problems worse (Hanrahan, 2009).
Discussion
The purpose of this review of the literature was to find out what impact nurse
leader’s involvement on inpatient psychiatric units has in terms of affecting burnout
among mental health nurses. Overall, the literature indicates that the presence of nurse
leaders on psychiatric units reduces burnout among mental health nurses (Bogaert et al.,
2012; Hanrahan et al., 2010; Kanste, Kyngäs & Nikkil, 2007). Leadership skills were
noted to be important especially in relation to emotional exhaustion and
depersonalization. Hanrahan et al. (2010) strongly suggested that skilled managers on
psychiatric units are incredibly important to the well-being of psychiatric nurses.
The literature identified key areas where nursing leaders can be effective in
preventing burnout in mental health nurses. The first area identified was in the nurse
leader communication. Communication was thought to be a critical component and
competency that nursing leaders need to possess. Effective communication enables nurse
leaders to build working relationships. Open communication in terms of sharing of
information with nurses was a found to reduce burnout. When nurse leaders are available
on the units and are genuinely concerned with the day-to-day issues affecting nurses on
50
the units, nurses are able to confide in them. This, in essence, allows the leaders to
identify nurses who are struggling with work or personal issues and provide resources to
help the nurses cope with stress before they burn out.
Clinical supervision was another component of nursing leadership that emerged
from the literature as a critical tool for preventing burnout among mental health nurses.
Clinical supervision as an intentional activity allows nurses to reflect on their clinical
practice under the guidance of a supervisor (Gonge and Buus, 2011). This kind of
supervision allows the nurse leader to identify gaps in the employee’s clinical practice
and provide guidelines and recommendations on how they can improve. When this is
done on a regular basis, nurses reported increased confidence and feelings of personal
accomplishment (Aiken, McClaine & Hanlon, 2010). Clinical supervision also helps the
employee to seek clarification and guidance from the leader and this can help nurses
become better practitioners. The literature indicated that clinical supervision can improve
nurse morale and prevent burnout as nurses feel supported and cared for (Sherring and
Knight, 2009). Findings by Hanrahan et al. (2010) also supported this as they showed a
strong and significant relationship between psychiatric nurses’ experiences of feeling
valued with lower rates of expressed emotional exhaustion and depersonalization.
In terms of psychiatric work environment, nursing leadership’s presence was
found to be a part of the psychiatry work environment that was instrumental in reducing
and preventing burnout in the mental health nurses. A feeling of being valued by a
supervisor was attributed to lower rates of emotional exhaustion and depersonalization
(Hanrahan et al., 2010). Nursing leaders on the unit are thought to improve peer relations
on the units and this helps create a productive work environment which, in turn, increases
51
job satisfaction and individual accomplishment. Being on the unit allows the leaders to
see changing needs of the nurses in real time and allows them to make needed resources
available in response to the changing needs, provide supervision, organization and
direction for the nursing staff. The literature indicated as well that nurse leaders on the
unit help to navigate the relationship between nurses and physicians which helps protect
against burnout (Hanrahan et al., 2010).
The literature review showed that the leadership style that is most effective in
reducing and preventing nurse burnout among mental health nurses is the
transformational leadership style. Through this style of leadership, it was found that when
leaders managed by exception, nurses felt valued which helped protect them from
depersonalization and increased their sense of accomplishment (Kanste, 2008). The nurse
leaders who do this assist in motivating, involving, and enhancing individual and
professional development of the staff nurses. For this to happen, it is essential that nurse
managers are available to the staff nurses on the units in order to understand their day-to-
day challenges as well as understand the nurses’ perspectives regarding the issues that are
affecting them.
Implications for Nursing Practice
Leadership skills like effective communication, active listening, conflict
management, teaching, mentoring and clinical supervision can be learned. According to
Hanrahan et al. (2010), building the needed skill set of psychiatric nursing leaders could
have a pronounced effect on the quality of the inpatient care environment and patient
outcomes and provide protection against nurse burnout. The transformational leadership
style which was identified as a leadership style that nurses are most comfortable with
52
may not be possessed by all nursing leaders. This implies that nurse leaders and
supervisors will need to be trained to ensure that they have the skills and tools they need
to help protect nurses against burnout. Education and interventions to both staff and
leaders about the effects of burnout will also help protect against burnout. The literature
review recommended that leadership programs and ongoing continuing education of
leaders and managers of inpatient psychiatric units that are tailored to psychiatric care
environment are necessary to help keep the leaders abreast with the tools they need to
mediate the stress of working with mentally ill patients. Nurse leaders and supervisors
should be more available to the mental health nurses and prioritize providing one-on-one
clinical supervision regularly. It was noted in the literature that there is extensive
communication among mental health nurses. Therefore, leaders need to be accessible on
the units to help foster effective communication and involve nurses in decision-making
processes as this is thought to help nurses feel included and valued.
It is also important for the nurse leaders in psychiatry to empower nurses and
strengthen the relationship between the nurses and supervisors and with other mental
health professionals. Nurse leaders in psychiatry would be invaluable in giving their
nurses adequate feedback about performance, provide social support, and identify
individualized encouragement to nurses in order to grow them professionally and help
ensure job satisfaction. The nurse leaders need to be proactive in providing support and
help the nurses manage negative feelings as well as assist them in identifying tools and
resources on coping with the stress of caring for aggressive patients.
53
Implication for Nursing Education
While the literature acknowledges that leadership courses offered in baccalaureate
programs are effective in providing student nurses with the fundamentals and theories of
leadership, the nursing programs do not go into details on how the leadership theories are
applied to the distinct nursing specialty areas (Hanrahan et al., 2010). The inpatient
psychiatric environment in general hospitals is very different from other inpatient units in
hospitals and therefore leadership training for leaders in psychiatric units should be
geared toward meeting the unique needs of the specialty area.
Recommendation for Nursing Research
The literature identified the transformational leadership style as a model that helps
protect mental health nurses from depersonalization and increased their sense of
accomplishment. However, more research is needed to explore unique leadership needs
for psychiatric care environments. Several studies noted that nurses who feel supported
and valued have lower levels of burnout. Research is therefore needed to find out specific
ways that are effective in helping mental health nurses feel supported. Further research is
also needed to explore the specific attributes of clinical leaders in mental health nursing.
Integration and Application of Selected Theoretical Framework
Modeling and Role-Modeling (MRM) theory as a conceptual framework has been
used as a foundation for research, education, and clinical practice in nursing. It is a theory
derived from practice because it supports theory-based nursing practice. While the theory
traditionally has been used to refer to the nurse-patient relationship, Schultz (2004) noted
that humans are alike and therefore the theory in essence describes human relationships.
54
The MRM theory, for the purpose of this literature review, was adapted to explain
the human relationship of nursing leaders and staff nurses working in inpatient psychiatry
units and the role the leaders can play in reducing and preventing nurse burnout. Leaders
employing the MRM theory can help reduce and prevent burnout among mental health
nurses by using the theory’s concepts of facilitation, nurturance, and unconditional
acceptance.
The MRM theory requires the nurse to place herself/himself in the position of the
patient in order to understand the patient’s world view or understand that which is most
important to them. MRM theory also postulates that most people know what they need to
do to improve and promote their well-being. Nurse leaders cannot assist nurses in
preventing burnout without accurately understanding the nurses’ perceptions in terms of
what they perceive as the problems causing them stress. The leaders will need to
understand that nurses know best how the problems that are causing them stress and
burnout come about and that they have the knowledge of how the problems can be
solved. In instances where the nurses may not know exactly what to do to cope, they are
aware that something needs to be done.
The nurse leaders can provide facilitation for the nurses by helping them succeed
in their work through the provision of support and needed resources for self-care. This
success, according to the MRM theory, will have to be defined by the nurses and be
clearly made known to the leader. The leader will need to actively listen to the nurses and
understand the nurses’ perceptions of the issues that are causing stress at work and
collaborate with the nurses in solving them. The literature review showed that nurses
working in psychiatry benefit from feeling valued by their leaders and that nurses who
55
perceive themselves as being valuable to the organization have lower rates of expressed
emotional exhaustion and depersonalization. Leaders will need to empower the nurses to
actively participate in identifying strategies that can be employed to prevent burnout. The
nurse leaders need to recognize and consider the psychiatry work environment including
patient assignment, milieu management, nurse-nurse interactions and nurse-physician
relationship as well as providing needed physical resources in planning and facilitating
the nurse’s success. When leaders assist in maintaining a productive and collaborative
culture, nurses feel supported, cared for, and valued.
Nurturance will be achieved by leaders working with mental health nurses if the
nurses perceive that leaders understand and are supportive of their values (Schultz, 2004).
This calls for the leaders to seek to understand the issues that cause the nurses stress from
the nurses’ point of view and to nurture and guide the nurses’ ability to come up with
strategies to work through the issues while at the same time providing resources to
achieve the desired results.
Schultz (2004) defines unconditional acceptance as an acceptance with
empathetic communication with no strings attached and a nonjudgmental respect of the
other person. Since MRM is a relationship based theory, both the nurse and the leader
have a part to play in preventing nurse burnout. The leaders will need to be visible and
accessible to the nurses in order to listen and develop an understanding of the nurses’
issues and perspectives while suspending their own opinions (Schultz, 2004). Clear
communication plays an important role for this understanding to happen as this will
enable the two parties to build a relationship based on mutual respect.
56
The MRM theory describes the concept of person as having several subsystems:
biological, psychological, social, cognitive, and spiritual systems. These subsystems all
have to be kept in mind by the leaders as playing a part in the nurse’s well-being at work.
Nurse leaders therefore, when dealing with nurse issues, should not just target one
subsystem perhaps because that is the one being manifest at a particular time but should
instead focus on all subsystems in order to view the nurse in a holistic manner (Schultz,
2004). The person subsystems are the internal stressors or strengths of the individual. If a
nurse for instance, is unable to perform a certain skill appropriately, this can be an
internal stressor, the leader needs to know and understand how this is affecting the nurse
and take appropriate action to help the nurse succeed without causing more stress.
According to the MRM theory, the concept of environment refers to the external
stressors, resources, and interactions (Schultz, 2004). The psychiatry nursing leader needs
to recognize the psychiatric nursing environment when planning and facilitating the
nurses’ success. Hanrahan et al., (2010) in their study on the relationship between
psychiatric nurse work environments and nurse burnout in acute care general hospitals
noted that the relationship between mental health nurses and other psychiatry providers is
very important. The nurse-physician relationship was found to be one of the strongest
predictors of psychiatric nurse burnout and when positive, it protects against burnout in
the area of emotional exhaustion and depersonalization. The same study found that
general hospitals that promote better nurse practice environments also have better nurse-
physician relationships and lower psychiatric nurse burnout (Hanrahan et al., 2010). The
nurse leaders therefore, if available and engaged on the nursing unit, can be instrumental
in helping navigate and nurture this important relationship.
57
Conclusion
This literature review and its discussion has shown the importance of leaders
getting involved in psychiatry units and establishing positive relationships with staff
nurses working in psychiatry. Caring for the nurses in terms of having daily interactions
with them and valuing the work they do is meaningful and brings purpose in their work.
This contributes to increased job satisfaction and consequently reduces stress and
burnout. Engaging and allowing nurses to identify job stressors and involving them in
problem solving (MRM theory) is an approach that the literature found to be effective in
empowering mental health nurses and protects them against burnout (Hanrahan et al.,
2010). Effective communication between nurse leaders and mental health nurses, as well
as communication with other providers, is important among mental health nurses. It is
important for nurse leaders to be visible on the psychiatry units in order to facilitate
communication and provide clinical supervision for the nurses in order to protect nurses
from burnout.
58
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